The fate of laparoscopic adjustable gastric band removal

Background: Long-term complications and lack of weight loss have caused a surge in laparoscopic adjustable gastric band (LAGB) removal. This study reviews the trend of LAGB removal and examines outcomes of patients undergoing subsequent revision bariatric surgery at a single tertiary care centre in Canada. Methods: All LAGB removals performed between January 2008 and December 2016 were reviewed. A subset of patients who underwent revision surgery was then analyzed for patient demographics, weight, body mass index and postoperative complications. Results: During the study period, 211 patients underwent LAGB removal (87.7% female). Most bands were inserted out of province. Reasons for band removal included dysphagia, band slip and weight recidivism. Fifty-nine patients (28%) underwent revision surgery at a mean of 12.8 ± 9.3 (range 0­55) months after LAGB removal. Mean age was 47 ± 9.7 (range 26­63) years, and mean pre-LAGB weight was 131.0 ± 30.0 kg. Following LAGB, the mean weight decreased to 120.5 ± 26.4 kg, but most regained weight after removal to a mean prerevision weight of 125.1 ± 27.0 kg. The lowest mean weight was achieved 12 months after revision surgery (98.7 ± 30.2 kg). The mean percent total weight loss was not significantly different after revision laparoscopic Roux-en-Y gastric bypass compared with revision laparoscopic sleeve gastrectomy (22.8 ± 9.6% v.17.5 ± 6.5%, p = 0.179). The overall revision surgery 30-day complication rate was 18.6% and increased to 23.7% long-term. No deaths occurred. Conclusion: The number of LAGB removals is increasing. Revision bariatric surgery leads to improved weight loss; however, revision surgery is associated with complications.

Contexte: Les complications à long terme et l'absence de perte de poids sont à l'origine de l'augmentation du nombre de retraits d'anneaux gastriques ajustables (AGA) installés par voie laparoscopique. Cette étude se penche sur la tendance aux retraits des AGA et sur les résultats chez les patients qui subissent une chirurgie bari atrique de révision par la suite dans un centre de soins tertiaire au Canada. Méthodes: Tous les retraits d'AGA effectués entre janvier 2008 et décembre 2016 ont été passés en revue. Un sous-groupe de patients ayant subi une chirurgie de révision a ensuite été analysé aux plans des caractéristiques démographiques, de la masse corporelle et des complications postopératoires. Résultats: Pendant la période de l'étude, 211 patients se sont fait retirer leur AGA (87,7 % de femmes). La plupart des anneaux avaient été insérés à l'extérieur de la province. Parmi les raisons invoquées pour les retraits, mentionnons dysphagie, glissement de l'anneau et reprise de poids. Cinquante-neuf patients (28 %) ont subi une chirurgie de révision en moyenne 12,8 ± 9,3 (éventail 0­55) mois après le retrait de l'AGA. L'âge moyen était de 47 ± 9,7 (éventail 26­63) ans et le poids moyen avant l'AGA était de 131,0 ± 30,0 kg. Après l'AGA, le poids moyen a diminué à 120,5 ± 26,4 kg, mais la plupart ont repris du poids après le retrait pour atteindre un poids moyen pré-révision de 125,1 ± 27,0 kg. Le plus bas poids moyen a été atteint 12 mois après la chirurgie de révision (98,7 ± 30,2 kg). La perte de poids totale moyenne en pourcentage n'était pas significativement différente après la dérivation de Roux-en-Y laparoscopique de révision, comparativement à la gastrectomie laparoscopique en manchon de révision (22,8 ± 9,6 % c. 17,5 ± 6,5 %, p = 0,179). Le taux global de complications des révisions chirurgicales à 30 jours a été de 18,6 % et est passé à 23,7 % à plus long terme. Aucun décès n'est survenu. Conclusion: Le nombre de retraits d'AGA est en hausse. La révision de la chirurgie bariatrique a amélioré la perte de poids, mais elle s'accompagne de complications.

Laparoscopic Nissen fundoplication controls reflux symptoms and improves disease-specific quality of life in patients with class I and II obesity.

BACKGROUND: Patients with class I obesity and refractory gastroesophageal reflux disease may not qualify for bariatric surgery, and the effectiveness of laparoscopic Nissen fundoplication remains controversial. This study evaluates the early efficacy of laparoscopic Nissen fundoplication in patients with class I and II obesity. METHODS: Data for patients who underwent laparoscopic Nissen fundoplication between 2009 and 2014 were collected prospectively. Cohorts were stratified based on body mass index at the time of surgery: Nonobese (body mass index <30 kg/m2), class I obese (body mass index 30-34.9 kg/m2), and class II obese (body mass index 35-39.9 kg/m2). Primary outcome measures were symptoms assessed using the gastroesophageal reflux symptom scale and the gastroesophageal reflux disease health-related quality of life questionnaires. RESULTS: One hundred seventy-six patients underwent laparoscopic Nissen fundoplication during the study period: 76 nonobese (body mass index 26.2 ± 2.9 kg/m2), 53 class I obese (body mass index 32.4 ± 1.5 kg/m2), and 47 class II obese (body mass index 37.7 ± 2.5 kg/m2). Baseline gastroesophageal reflux symptom scale scores were 35.5 (6-72), 37.0 (5-72), and 45.0 (5-72) in nonobese, class I obese, and class II obese groups, respectively. Six weeks postoperatively, scores decreased to 6.5 (0-72), 4.0 (0-27), and 9.0 (0-64), respectively (P < .001). After 18-months, scores remained improved at 8.0 (0-72), 5 (0-48), and 4 (0-62), respectively (P < .001). A similar trend was seen in gastroesophageal reflux disease-health-related quality of life scores. Overall, 86%, 83%, and 79% remained free of proton-pump inhibitor medications, respectively. CONCLUSION: Laparoscopic Nissen fundoplication provides similar symptom control and quality of life 18-months postoperatively in nonobese and class I and II obese patients. Thus, laparoscopic Nissen fundoplication represents a viable surgical option for patients with class I and II obesity.

Revision of sleeve gastrectomy to Roux-en-Y Gastric Bypass: A Canadian experience.

INTRODUCTION: Sleeve gastrectomy (SG) can be associated with inadequate weight loss, insufficient resolution of co-morbidities and severe reflux. Conversion to Roux-en-Y Gastric Bypass (RYGB) is a potential solution. The aim of this study was to determine the common indications for conversion from SG to RYGB at our centre, and evaluate patient outcomes with respect to weight loss and co-morbidity resolution. METHODS: A retrospective review of patients who underwent conversion from SG to RYGB between 2008 and 2015. RESULTS: 273 SGs were performed of which 6.6% (n = 18) were converted to RYGB most commonly due to inadequate weight loss (65.3%) and severe reflux (26.1%). Two patients were converted as a planned two-stage approach to RYGB. Patients went from a mean preoperative BMI of 50.5 to a mean BMI of 40.5 post-SG on average by 20.9 months. The mean time to conversion was 41.8 months. There was a positive correlation between pre-SG BMI and time to conversion (p = 0.040). The mean BMI after conversion was 36.4, but this additional weight loss was not significant (p = 0.057). After conversion, four of the five diabetic patients are now medication free and 75% of patients no longer have reflux symptoms. All patients had complete resolution of their hypertension and obstructive sleep apnea. Revision perioperative complication rates were comparable to primary RYGB. Two patients developed new onset iron deficiency anemia. CONCLUSION: Revision to RYGB is a safe option for SG failure and resulted in significant benefits from co-morbidity resolution.

Laparoscopic sleeve gastrectomy in morbidly obese patients with end-stage heart failure and left ventricular assist device: medium-term results.

BACKGROUND: Morbid obesity precludes patients with end-stage heart failure from becoming cardiac transplant candidates. This study evaluates the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) as a means to transplant candidacy in such patients. METHODS: Morbidly obese patients with end-stage heart failure, who were ineligible for cardiac transplantation and underwent LSG between 2008 and 2013, were reviewed retrospectively. Demographic characteristics, perioperative details, percentage of excess weight loss (%EWL), and status of transplant candidacy were analyzed. RESULTS: Six patients (3 men) with end-stage heart failure and morbid obesity underwent LSG. Three patients (50%) had a left ventricular assist device (LVAD) in place at the time of surgery. Median age was 34 (31-66) years and mean preoperative body mass index (BMI) was 47.6±3.0 kg/m2. Median operative time was 90 (66-141) minutes, with a median length of stay of 7 (4-16) days. There were no perioperative deaths. One patient suffered a spontaneous flank hematoma. The same patient also had thrombosis of the LVAD pump at 3 weeks postoperatively, requiring an uneventful device exchange. At median follow-up of 22 (12-70) months, the mean %EWL was 51.4±10.3% with a decrease in BMI to 34.3±2.4 kg/m2 (P<.05). All patients had lost sufficient weight to become transplant eligible within 12 months of surgery. Two patients had undergone successful transplantation and another 2 were on the transplant list. CONCLUSION: LSG appears to be a safe, technically feasible, and effective method for obtaining adequate weight loss in morbidly obese patients with end-stage heart failure and mechanical circulatory support, subsequently improving their access to cardiac transplantation. This is the largest case series to date of this high-risk group of patients undergoing LSG.

Efficacy and durability of robotic Heller myotomy for achalasia: patient symptoms and satisfaction at long-term follow-up.

BACKGROUND: Laparoscopic Heller myotomy (LHM) has become the standard treatment for achalasia in the USA. Robot-assisted Heller myotomy (RHM) has emerged as an alternative approach due to improved visualization and fine motor control, but long-term follow-up studies have not been reported. We sought to report the long-term outcomes of RHM and compare them to those of LHM. METHODS: A retrospective cohort study was performed for patients who underwent laparoscopic or RHM between 1995 and 2006. Long-term follow-up was performed via mail or telephone questionnaire. The primary outcome measure was durable relief of dysphagia without need for further intervention. Secondary outcomes included gastroesophageal reflux symptoms, disease-specific quality of life, and patient satisfaction with their operation. RESULTS: Seventy-five patients underwent laparoscopic (n = 19) or robotic (n = 56) myotomy during the study period. Long-term follow-up was obtained in 53 (71 %) patients with a median interval of 9 years. RHM was associated with a decreased mucosal injury rate (0 vs. 16 %, p = 0.01) and median hospital stay (1 vs. 2 days, p < 0.01) compared to conventional laparoscopy. All patients reported initial dysphagia relief, and 80 % required no further intervention. This did not differ between groups. Sixty-two percent required medications to control reflux symptoms at long-term follow-up, including 56 % following robotic myotomy and 80 % after laparoscopic myotomy (p = 0.27). Overall, 95 % of patients were satisfied with their operation, and 91 % would choose surgery again given the benefit of hindsight. CONCLUSION: There is a dearth of long-term follow-up data to support the effectiveness of RHM. This study demonstrates durable dysphagia relief in the vast majority of patients with a high degree of patient satisfaction and a low rate of esophageal mucosal injury. While a significant proportion of patients report reflux symptoms, these symptoms are well controlled with medical acid suppression.

Elective antireflux surgery in the US: an analysis of national trends in utilization and inpatient outcomes from 2005 to 2010.

BACKGROUND: Previous research suggested that antireflux surgery reached its peak volume in the US more than a decade ago. Factors such as changes in population demographics and improvements in surgical outcomes may have reversed this decline. We sought to examine national trends in the management of antireflux surgery patients and identify patient and hospital characteristics associated with postoperative complications. METHODS: We analyzed data from the Nationwide Inpatient Sample to identify adults with gastroesophageal reflux disease or esophagitis who underwent elective antireflux surgery between 2005 and 2010. Patient and hospital characteristics were analyzed. A multivariate logistic regression model was used to identify characteristics associated with an increased risk of postoperative complications following laparoscopic antireflux surgery. RESULTS: The volume of elective antireflux surgery remained relatively stable between 2005 (n = 15,819) and 2010 (n = 18,780). The percentage of patients older than 64 years of age increased from 21.1 % in 2005 to 30.9 % in 2010 (p < 0.01), while the percentage with a Charlson score over 2 more than doubled (1.2-2.7 %; p < 0.01). Inpatient complication rates (6.3 vs. 6.6 %; p = 0.21) and mortality (0.08 vs. 0.21; p = 0.72) were unchanged. On multivariate analysis, patients older than 79 years were three times as likely to develop a complication (odds ratio [OR] 3.1; 95 % CI 2.1-4.5) as were patients with a Charlson score over 2 (OR 3.1; 95 % CI 2.2-4.3). CONCLUSIONS: Today's antireflux surgery patient population is a higher-risk cohort, but complication rates have remained stable and inpatient mortality has declined more than 50 % over the past decade. Given these findings, additional research is needed to understand why antireflux surgery is underutilized, with a decline of more than two-thirds since its peak in 1999.

Robotic-assisted colon and rectal surgery: a systematic review.

BACKGROUND: Colorectal surgery is one of the most common procedures performed by general surgeons, with an increasing number being performed laparoscopically. Robotic technology is emerging in the ongoing evolution in minimally invasive surgery. This study systematically reviews the literature regarding the safety and feasibility of robotic-assisted colorectal surgery. METHODS: A comprehensive search of electronic databases was completed for the period 2000 to 2010. Two independent reviewers assessed the studies for relevance and inclusion, and extracted data. RESULTS: After an initial screen of 347 titles, 20 studies met the inclusion criteria. A total of 854 patients were included with a mean age of 61 years and a body mass index of 25.5 kg/m(2) . Major complications included 27 anastamotic leaks (27/766 = 3.5%), 10 post-operative bleeds (1.1%) and 14 post-operative infections (1.6%). There were no mortalities reported. CONCLUSIONS: This systematic review demonstrates that robotic-assisted colorectal surgery is emerging as a safe and feasible option in colorectal surgery.

Correlation between saliva production and quality of life measurements in head and neck cancer patients treated with intensity-modulated radiotherapy.

PURPOSE: To investigate the strength of correlation between measured saliva flow rates and various toxicity endpoints commonly used in head and neck cancer (HNC) treatment. MATERIALS AND METHODS: All patients enrolled in a phase II study using intensity modulated radiotherapy (IMRT) for HNC treatment underwent whole mouth saliva flow measurements (stimulated and unstimulated). They were also assessed for salivary gland toxicity using Radiation Therapy Oncology Group (RTOG) late toxicity grading and 9 items representing patient-graded toxicities from 2 questionnaires (Xerostomia questionnaire and University of Washington quality of life). For each patient, saliva flow rates and quality of life (QOL) data were collected preradiotherapy (RT) and at 3 intervals post-RT (3, 6, and 12 months). RESULTS: A total of 188 sets of coregistered data were obtained for 47 patients over a period of approximately 4 years. Saliva production and mean QOL dropped significantly immediately after RT, but there was a statistically significant recovery in both parameters between 3- and 12-month post-RT. By 12 months, post-RT the mean QOL scores had returned to pre-RT baseline, although mean stimulated saliva production remained 58% below baseline. CONCLUSION: Patients with HNC treated with IMRT experienced a small drop in QOL which recovered to baseline by 12 months post-RT. There was no statistically significant correlation seen between global health-related QOL scores and stimulated saliva production rates in the post-RT period.